Closed injuries and injuries to the scrotum and testicles

In peacetime, closed injuries and injuries of the scrotum and testicle prevail, the frequency of which is 9-13% of all injuries of the genito-urinary organs. Closed damage to the scrotum and testicles in peacetime occurs more often (up to 80%) than the open ones (19.4%), spontaneous (0.5%) and dislocating lesions (testicular dislocations - 0.1%). Closed injuries and injuries of the scrotum and testicle due to thermal, radiation, chemical, damage, electric trauma are rare.

[1], [2], [3]

What causes closed injuries and scrotal and testicular injuries?

When a scrotum is injured, its organs are damaged less often than the scrotum itself (in 25-50% of cases), since it is believed that at the time of injury there is a reflex contraction of the muscles that raise the testicles, and the latter usually migrate from the zone of exposure to traumatic force. Closed trauma leads to rupture of the testicle in those cases when a strong blow falls on the testicle, located directly at the pubic bone. In some cases, suddenly applied force can push the egg upward towards the inguinal canal or even through it into the abdominal cavity. These injuries are more common in road traffic accidents in motorcycle drivers due to a sharp and sudden impact on a wide gasoline tank. Such a dislocating lesion, called a testicular dislocation, is very rare. Dislocation can be one- and two-sided, and the dislocated testicle is usually not damaged.

AND I. Pyytel (1941) divided the closed dislocations of the testicle into two groups: external (subcutaneous) and internal. The first include inguinal, pubic, femoral, perineal, as well as dislocation under the skin of the penis, to the second - dislocations in the inguinal and femoral canals, intra-abdominal and acetabular. In this case, the inguinal and pubic dislocations of the testicle most often develop.

Injury of the scrotum and testes is recorded in all age groups, but most often it occurs in adolescents and men aged 15 to 40 years. 5% of patients with scrotal and testicle trauma are children less than 10 years old. The literature also describes damage to the testicles in newborns with breech presentation of the fetus. Closed injury of the scrotum and testicles, as a rule, is isolated damage, but if the penetrating object acts as the cause, a contralateral testicle, penis and (or) urethra can be used. When traumas of male genital organs are most often involved in the process of both the scrotum and the testicles on both sides. One-sided damage occurs much less often (1-5% of cases).

Symptoms of a scrotal and testicle injury

With closed injuries (bruises, infringements) of the scrotum, due to its abundant vascularization and looseness of the connective tissue, superficial hemorrhages often form in the form of massive bruises and hemorrhagic infiltration, often extending to the penis, crotch of the inner thighs, the anterior wall of the abdomen.

At the same time poured blood accumulates in the wall of the scrotum, not penetrating deeper than the external seminal fascia. Pain with closed trauma is usually not intensive and is soon followed by a feeling of heaviness and tension in the scrotum. Because of a hemorrhage, the skin of the scrotum acquires a purple-blue, sometimes almost black color. When palpation of the scrotum is determined by moderate soreness, blood-infiltrated tissues have a testic consistency. However, through the wall of the scrotum it is often possible to feel the testicle, its appendage, the spermatic cord.

Simultaneously with the scrotum, her organs can be damaged, with one, less often on both sides. In this case, closed (subcutaneous) bruises and ruptures of the testicle, its epididymis, the spermatic cord and the membranes of these organs are possible. Such damage is accompanied by the formation of deep hemorrhages (hematomas), which are divided into extravaginal and intravaginal.

In extravaginal hemorrhages, spilled blood does not penetrate deeper than the vaginal sheath of the testicle. Dimensions of the hematoma may be different, and it is. As a rule, has no clear boundaries. In some cases, the hemorrhage is small and palpable in a limited area of the spermatic cord, in others - hemorrhagic infiltration extends from the testicle to the external opening of the inguinal canal. Such hemorrhage occurs when the elements of the spermatic cord and the testicles are damaged, located outside of the vaginal membrane. With these hemorrhages, it is possible to feel the testicle.

Intravaginal hemorrhages (hematomas) are called traumatic hematocele. This type of hemorrhage occurs with damage to the testicle or its vaginal membrane. When examined and palpated, such a hemorrhage can be mistaken for a dropsy of testicular shells. A typical haematoceles occurs as a result of rupture of the testicles during their dropsy. Decisive in the diagnosis are correctly collected anamnesis of the resulting injury, tenderness in palpation, a negative symptom of translucence.

However, it is not always possible to clearly distinguish between extravaginal and intravaginal hemorrhages. Severe injuries lead to the accumulation of blood in various layers of the scrotum and a combination of various hemorrhages.

Closed or subcutaneous injuries of the scrotum, especially the testicle and epididymis, causing severe pain, are often accompanied by vomiting, convulsions, fainting, shock. Often there is an increase in the volume of the scrotum, tension, a non-palpable testicle. Expressed hematocele can develop even without damage to the testicle.

Dislocation of the testicle is often detected in patients with polytrauma (based on CT of the abdominal cavity). When dislocation (dislocation) the egg is most often not damaged, but sometimes it twists in the area of the spermatic cord, which is promoted by a wide inguinal canal, false cryptorchidism. This leads to a violation of blood supply to the body. The twisting of the dislocated testicle is accompanied by the rupture of its belly coat. Diagnosis of testicular dislocation immediately after the trauma does not cause difficulties, although in serious accidents, multiple injuries of organs can be detected in the victims, and the "missing" testicle may go unnoticed. If the patient is conscious, he may complain of severe pain in the groin. At the examination, the empty half of the scrotum is determined, often the testicle can be palpated in the groin area. Palpation of the displaced testicle is sharply painful.

Closed damage to the spermatic cord is relatively rare, since the spermatic cord is well protected. As a rule, with lesions, only the contusion of the spermatic cord is determined, which does not require surgical intervention. The latter is possible when hematomas are large.

Complications of scrotal and testicle injury

The consequence of damage to the testicles and subsequent traumatic orchitis and periorhitis are sclerotic and atrophic changes in the testicle parenchyma. Education and suppuration of the hematomas occur with an unreasonable refusal of surgery and drainage of the wound. Preventing these complications is the timeliness and thoroughness of the operation and the use of antibiotic therapy.

[4], [5], [6]

Diagnosis of scrotal and testicle injury

Despite the pronounced clinical picture, the diagnosis of closed damages of the scrotum organs is often difficult due to concomitant damage to the scrotum.

[7], [8], [9], [10], [11]

Instrumental diagnosis of scrotal and testicle injury

With blunt damage to the testicles, the use of ultrasound is the subject of controversial discussions, since the sensitivity and specificity of this method are different. However, as a means of primary research, ultrasound takes its significant place, since it makes it possible to diagnose intra- and / or extestesticular hematoma, testicular rupture, sometimes even a testicle or foreign body.

Some authors believe that the use of ultrasound is indicated only in those cases when hematocele is not present (hydrocele is considered an indication for the operation), and the data of the physical examination are not informative.

Summarizing what has been said, it can be concluded that ultrasound is indicated if conservative treatment is supposed to be performed, and for this purpose, normal ultrasound data can serve as a justification. We also note that traumas of the epididymis are poorly susceptible to ultrasound transmission.

Information obtained with ultrasound may be supplemented with Doppler-duplex tomography, which provides information on the status of testicular perfusion, as well as the ability to identify vascular lesions and false aneurysms.

For the recognition of subcutaneous testicle ruptures, ultrasound and MRI are informative. Additional information for scrotal injury can be given by CT or MRI. But sometimes even with the help of these studies it is impossible to accurately determine the nature of the damage to the scrotum and its organs and exclude damage to the testicle. In such situations, surgery is shown - scrotal revision.

Differential diagnosis of scrotal and testicle injury

Recognition of a testicle dislocation immediately after an injury is not difficult. The dislocation is manifested by pain in the place of the displaced testicle, its absence in the scrotum, where it was before the injury. Palpation of the displaced testicle is sharply painful. Elderly dislocation of the testicle from its delay or ectopia helps to distinguish carefully collected anamnesis.

With damage to the scrotum, twisting of the spermatic cord and testicle may occur, which is facilitated by a wide inguinal canal, false cryptorchidism.

[12], [13], [14], [15]

Treatment of scrotal and testicle injury

Treatment of closed scrotal injury depends on the nature and severity of the lesions.

Non-drug treatment of scrotal and testicle injury

Contusions with the formation of superficial hemorrhages and with minor hemorrhagic infiltration of the scrotal wall are treated conservatively. In the first hours after the injury, immobilization of the scrotum is performed, which is elevated by imposing a suspension or a pressure bandage. For local cooling of the damaged scrotum, use an ice pack wrapped with a towel. Beginning from the 2nd-3rd day after the trauma, thermal procedures increasing in intensity are applied: warming compresses, hot-water bottles, sallux, sessile baths, paraffin applications. Abundant blood supply to the scrotum facilitates rapid resorption of hemorrhages.

If only haematoceles are present without a testicle rupture, then conservative treatment is possible if the haematocel does not exceed the volume of the contralateral testicle by 3 times. However, this approach can not be considered a standard, since with large hematoceles, the need for delayed (more than 3 days) surgery and orchiectomy is quite high, even in the absence of testicular rupture. Later, intervention in 45-55% of cases leads to the need for orchiectomy, and the factors contributing to this are pain and infection. Contrary to the above: early surgical intervention makes it possible to save the testicle in more than 90% of cases and shorten the duration of hospitalization.

Operative treatment of scrotal and testicle injury

With closed trauma of the scrotum and its organs, conservative methods of treatment have recently prevailed. At the same time, active operational tactics are now recognized as more preferable than waiting tactics. Clinical experience shows that earlier (in the first hours and days after trauma) surgical intervention is the most effective way of maintaining the viability and function of testicular tissues, contributing to the patient's early recovery in comparison with the waiting tactics.

Indications for early, i.e. In the first hours and days after trauma, surgical treatment - testicle rupture, extensive superficial hemorrhage of the body of hemorrhagic scrotal infiltration; deep hemorrhages, especially with their rapid build-up and combination with severe pain, nausea, vomiting, shock; closed dislocation of the testicle after an unsuccessful attempt at bloodless repositioning, twisting of the spermatic cord. In favor of surgical treatment, the presence of doubts is inclined. That the damage to the scrotum and its organs is more serious than a simple bruise.

Indications for surgery at a later date are long-term, non-absorbable scrotum hematomas. There are practically no contraindications to the operation with isolated closed injuries of the scrotum and its organs.

In case of severe combined trauma, the operation on the scrotum can be performed in the number of measures of the second stage. Preoperative preparation is usual. Trimecaine, procaine (procaine) blockade of the spermatic cord is indicated for severe pain and shock, arising from damage to the testicle, its appendage. At the same time, conventional anti-shock measures are carried out. With extensive scrotal hemorrhage, the blockade is performed by infiltration with a solution of trimecaine, procaine (novocaine) of the spermatic cord within the inguinal canal. With isolated closed injuries of the scrotum and its organs, surgical interventions can be performed under local infiltration anesthesia in combination with a conductive one.

Depending on the damage, carry out:

• removal of superficial and deep hematomas and definitive stopping of bleeding;
• revision of the organs of the scrotum, the removal of apparently nonviable testicular tissues of its epididymis, membranes;
• imposition of catgut stitches on the egg white shell, testicular resection, its removal, ependymectomy;
• re-entry of the testicle into the scrotum and its fixation during dislocation, untwisting of the spermatic cord and fixation of the testicle in the normal position when the spermatic cord is twisted:
• stitching of the vas deferens or its dressing.

When the white shell of the testicle ruptures, the swelling tissue of the parenchyma is cut off from the healthy tissue and the belly coat is sutured with absorbable sutures. The vaginal membrane is sutured over the testicle and set within its limits to a small 0.5-0.6 cm diameter drainage, which is withdrawn through the lower part of the scrotum. With scalped wounds, the scrotum of the testicles is temporarily placed under the skin of the hip or suprapubic region. With open lesions, the use of broad-spectrum antibiotics is necessary.

If the spermatic cord is damaged or the testicle is detached in most cases, it is not possible to perform reconstructive operations. Because of this, it is possible to resort to expectant management, especially if both testicles are damaged, since the peculiarities of the blood supply to the scrotum and its organs, the development of collateral vessels in some cases are able to ensure the viability of the damaged testis and its appendage when the spermatic cord is separated. Separation of the scrotum and its organs occurs, as a rule, with careless handling of rotating machinery in the workplace. In most cases, damage to the testicles with this trauma is total and does not allow performing a reconstructive operation. The cases in which a microsurgical operation may be required include deliberate amputation of the scrotum and testicles by mentally unhealthy people. If the testes are preserved, an attempt may be made to microsurgical revascularization within the next few hours after the trauma.

If the testicle is located, if there are no other serious lesions, and the testicle is not changed during palpation, the patient is given an intravenous anesthesia to improve the condition and stop the pain. With cautious massaging movements, you should try to push the testicle back into the scrotum. If this fails or if there are doubts about the structural integrity of the testicle. The patient must be taken to the operating room for routine revision, during which the integrity of the testicle is restored and transferred to the scrotum.

Thus, when the testis is hanged out, the closed repositioning of the dislocated testicle is first of all shown, with its ineffectiveness - an open audit, during which orchitis or, if the organ is unviable, an orchiectomy. It is proved that even with bilateral dislocation, orchipexy does not lead to a deterioration in the sperm count.

All operations for a testicle injury are completed by draining the wound and applying a bandage to give the scrotum an elevated position. The most serious complication of closed lesions is gangrene of the scrotum.